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Equipment in Laparoscopic Surgery

Chapter · January 2015

DOI: 10.5005/jp/books/12446_2

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Section 1
To Know your Basics

● Equipment in laparoscopic surgery

● Peritoneal Access in laparoscopic Surgery
● Principles of Laparoscopy: Port Placement and
Trocars

Equipment in Laparoscopic Surgery
Before a new instrument is used, the surgeon should know and test it. It is always better to test
a device before a procedure than during it!
Introduction
Over the last 30 years, laparoscopic procedures have
become standard in most surgical diseases. The rise of
abdominal and pelvic laparoscopic surgery has been a true
revolution in medical practice. The concept of minimally
invasive approach, with all its advantages such as quicker
recovery, shorter hospital stay and a far superior aesthetic
results has been gaining more and more supporters among
the international surgical community. The old paradigm
that a big incision meant a big surgeon has dramatically
changed.
The equipment and instruments for performing these
minimally access procedures has, over the years, greatly
improved. Following the surgeons’ demands, the increasing
investment and research on better tools have provided
more sophisticated and efficient equipment that offers
lower risk and thus higher safety to our patients.
An organized and well-equipped operating room is
essential for successful laparoscopy. The surgical team
and the operating room staff should be familiar with the
instruments and their functions. If they are not aware of
an instrument’s mechanism of action, it can interfere with
surgery progression, increasing not only risks for patients
but also surgeon’s anxiety and fatigue. Each instrument
should be inspected periodically. Scissors, graspers,
trocars, trocar sleeves are checked for loose or broken tips,
CHAPTER 1
Helder Ferreira, Carlos Ferreira
even if the same instruments were used during a previous
procedure.
One of the most important benefits of laparoscopy is the
magnified vision offered by the optics and high definition
cameras and thus better identifies anatomical structures
and dissection plans. This improved image often permits
a more precise surgical gesture, better hemostasis and
probably less postoperative adhesions.
Almost all instruments available for laparotomy are
now available in a specialized form for laparoscopy.
Instruments and devices that are used in laparoscopy
include the laparoscope (camera), trocars and port devices,
instruments for dissection, hemostasis and ultrasound.
Laparoscopic instruments attempt to reproduce the effects
of conventional laparotomic instruments: Grasping,
dissecting, cutting and coagulation.
LAPAROSCOPY VERSUS OPEN
SURGERY
Operative laparoscopy requires an advanced degree of
technical skills and training. The smaller size incisions and
instruments implicate a huge degree of precision only dealt
by imaging systems of high magnification.
In spite of the same final objective, we have to
distinguish the laparoscopic field from the open surgery
4 Manual of Minimally Invasive Gynecological Surgery
field. Contrary to open surgery where surgeons have a direct
view and manually manipulate and palpate tissues during
the operation, the challenge in laparoscopy is the absence
of stereoscopic vision and the need of transpositioning the
movement of surgeons’ hand through a long small diameter
trocar creating one or more output functions at the distal
part of body cavity.
Some of the specificities of laparoscopic surgery are:
TT Limited field of vision controlled by an assistant:
Surgeons need an increased cognitive and physical
load to perform the surgery (i.e. the instruments may
intermittently disappear from the surgeon’s vision while
manipulating structures).
TT Reduced depth perception: The monitors used in
laparoscopic surgery filter three-dimensional cues from
the operative field such as interposition or overlap,
lighting, outline and texture.1 The effect of reduction
in depth cues can be inferred from performance
differences under different viewing conditions, as
3D video systems that restore stereoscopic vision are
currently available.
TT Impaired hand-eye coordination: The main variables
are the location of the monitor, degree of amplification,
mirrored movement and misorientation.2
TT Motion limitation: The trocar restricts movement by
acting as invariant points. 3 The surgeon´s dexterity
is affected because the range of motion is reduced to
four degrees of freedom compared to six needed to
perform free motion. This movement restriction leads
to increased physical discomfort.
TT Reduction of haptic feedback: The role of haptic feedback
is of special interest because it is used in important
decision-making scenarios such as the discrimination
of healthy versus abnormal tissues, identification of
organs and motor control. In laparoscopic surgery, it is
reduced but not absent as in robotic surgery.4-5
TT Vision is dependent on the cleanliness of laparoscopic
optic, intra-abdominal smoke and light absorption:
Irrigation, blood, organic fluids, intra-abdominal
pressure and smoke can impair surgeon vision. The
irrigation of the operative field should be minimal as
the mixture of blood with serum alters light absorption
creating difficulties to discriminate structures and
surgical planes. Equilibrium is necessary between smoke
evacuation and pneumoperitoneum preservation.
Imaging Devices
Minimally invasive surgery resulted from the introduction
of new imaging devices at look to internal organs through
pericentimetric or shorter incisions. Surgical scopes are
recognized as very old medical instruments conceived
many centuries ago when simple hollow tubes were used
to observe intracorporeal cavities. Philip Bozzini in 1805
used the first illuminated scope consisted in a viewing
tube with a series of mirrors which reflected light from a
burning wax candle. However, only in the 20th century, a
light scope was used to perform a diagnostic laparoscopy
and only after the success obtained with laparoscopic
cholecystectomies (1986), the medical industry started to
develop better imaging and optical devices.6
Although the skepticism of some during the years, today
we are facing a rapid advancement of minimally invasive
surgery in different disciplines and pathologies, and in
parallel, new imaging devices are appearing. The surgeon
must be familiar with these developments.
Laparoscope: Traditionally, the laparoscope is a rigid
endoscope which is made of an outer ring of optical fibers,
used to transmit light into the abdominal and pelvic cavity
and an inner core of rod lenses via which the illuminated
operative field is captured by a camera. Digital imaging
chips located within the camera allow the image from the
scope to be transmitted to an external display.
Various different types of laparoscope are available,
specified in terms of overall length, number of rods,
diameter and angle of view. The diameter of laparoscopes
varies from 3 mm to 12 mm and the objective located
at the distal end offers an angle of view from 0 to 120
degrees. The brightness of the image is lower in thinner
scopes, due to less light transmission through the central
channel lenses. However, with the improvement in the
optical fiber technology, even laparoscopes with 3 mm
of diameter are able to produce brighter and clearer
images. The “angle of view” enables the operator to see
objects that might otherwise be out of camera view. A 30º
telescope provides a total field of view of 152º enabling
the visualization of the anterior abdominal wall and
working around masses or within deeper spaces. A 0º
telescope provides a field of view of 76º, but offers a
panoramic view and more usual perspective (Fig. 1).
There is a laparoscope model that has the possibility of
changing the view angle from 0° to 120º (Fig. 2). Flexible
tip laparoscopes are also available.
In gynecology, telescopes without instrument channels
are used in the majority of cases, as they give a better
overview and offer better image resolution. However, in
some cases, it may be useful to use telescopes with an
integrated instrument channel (Fig. 3). These laparoscopes
are generally 0º straightforward scopes. The diameter of
the instrument channel is 5–7 mm; thus, a correspondingly
large instrument can be inserted. CO2 laser can also be
connected to this laparoscope.

Fig. 1: Rigid laparoscopes 0°, 30°
Fig. 2: EndoCameleon® by Karl Storz (direction of view can be
adjusted ranging from 0°–120°
Fig. 3: Rigid laparoscope with a working channel
In gynecology, a good application for these instruments
is in performing laparoscopic sterilization. In addition,
tissue fragments or biopsy specimens can also be extracted
with the aid of a grasping forceps introduced through
the telescope’s instrument channel. On other hand, a
disadvantage of using telescopes with instrument channels
is the deterioration in image quality. This is due to the
lower light intensity that can be picked up by the video
Equipment in Laparoscopic Surgery 5
camera, when compared with telescopes that do not have
an instrument channel.
The light sources and light cables: No light, no
laparoscopy! The light is transmitted from a light source
(located separately off the patient table) to the operative
field through a light cable and the fiber bundle in the
laparoscope. High-intensity light is created with bulbs of
halogen gas, xenon gas or mercury vapor. The bulbs are
available in different potencies (150 and 300 Watts) and
should be chosen based on the type of procedure being
performed.
Nowadays, there are two types of light cables available:
fiberoptic or liquid crystal gel cables. Fiberoptic cables are
made up of a bundle of optical fiber glass thread swaged
at both ends. Light transmission occurs by total internal
reflection and is improved with an increasing number of
light fibers and increased diameter cable. These cables offer
little light loss but are less durable than the liquid-filled
light guide cables, because, some optical fibers break with
continuous usage. However, the liquid crystal gel cables are
made more rigid by a metal sheath, which makes them less
flexible and more difficult to maintain and store.
Laparoscopic Camera
A high quality image is essential to perform the procedure
safely. The laparoscopic camera has undergone some of
the biggest changes in the last decade. Most endoscopic
surgery is being done now with high-definition technology.
With this improved image quality cameras, the surgeon
can more readily identify the relevant anatomy. Nowadays,
systems that produce three-dimensional images are
currently under development and seem to facilitate
surgical performance.7
Fig. 4: 3D Laparoscopic camera by Karl Storz
6 Manual of Minimally Invasive Gynecological Surgery
Video Monitors
The sizes of the screen vary. To accommodate high-
definition cameras, the medical industry has adopted
the flat-panel monitors whose resolution determines a
better image. Some monitors include sterile touchscreen
functionality, offering the surgeon control over the entire
imaging system via the monitor.
Video Recording Systems
The video recording systems document and record the
performed procedures. They are of paramount importance
for scientific and educational purposes.
CO2 Gas Insufflator
The pneumoperitoneum offers the surgical field and the
access for the procedure itself. Conventional gas insufflators
are sufficient for a purely diagnostic laparoscopy. However,
in surgical laparoscopies performed today, accurate
pressure control insufflators are necessary to compensate
considerable volume losses that occur, for example due
to frequent suction of irrigation solutions using high-
performance irrigation-aspiration units. High-flow CO2
insufflators are a basic prerequisite for surgical laparoscopy,
as they monitor intra-abdominal pressure constantly and
halt the flow immediately when the set intra-abdominal
pressure is reached. Electronically controlled insufflators
have become the preferred choice in this respect. The
insufflator’s display indicates all the vital information that
is needed for the surgeon (Fig. 5):
TT Patient’s intra-abdominal pressure (should not exceed
a value of 15 mm Hg)
Fig. 5: High-flow CO2 insufflator by Karl Storz
TT Rate of inflow of the gas
TT Volume of CO2 insufflated
TT Gas reserve.
When the pressurized CO2 expands, it cools down and
has the potential to reduce the body temperature of the
patient. Some insufflators are equipped with facilities to
heat the CO2 before its passage into the abdomen. In order
to avoid the disadvantages of CO 2 insufflation, gasless
laparoscopy could be an alternative.
Ports of Entrance in Abdominal
Cavity
Veress Needle
Disposable and reusable Veress needles for creating
pneumoperitoneum are available. Veress needle is used
to create the initial pneumoperitoneum. A trocar can be
introduced safely because the distance from the abdominal
wall to the organs is increased. The Veress needle technique
is the most widely practiced method to access the peritoneal
cavity. Veress needle compromises two components—an
outer hollow needle with a sharp beveled edge, and an
inner, spring-loaded, retractable blunt obturator with the
stop position beyond the tip of the hollow needle. Once
the peritoneal cavity is entered, the blunt obturator is just
forwarded by the spring-force and protrudes beyond the
tip of the hollow needle, thus preventing from iatrogenic
visceral and vascular injuries.
The reusable type should be preferred to reduce the
costs of laparoscopic surgery. Verress needles are available
in three lengths: 80 mm, 100 mm and 120 mm. In the thin
patients, with scaphoid abdomen, an 80 mm Verress needle
should be used. In obese patients, a 120 mm Veress needle
is preferred. Disposable needles do not require cleaning or
sterilization procedures. The Veress needle must be kept
in perfect condition to ensure that the mandarin slides
easily into the protective sleeve. The surgeon must have
full knowledge of all safety features of the mandarin. The
Verress needle should be held between the thumb and the
index finger during insertion. When the needle is inserted
through the abdominal wall, passage through the fascia
into the peritoneal cavity can be recognized as a tactile
“popping” sensation.
Trocars
The trocars establish a small interface between the surgeon
and the surgical field. The trocars are the accesses through
which the surgeon goes inside the abdominal cavity,

A B
Figs 6A and B: Reusable trocars 3.5, 5.5, 11, 12 (Karl Storz)
establishing a shaft and support for different instruments.
In the time of cost reduction, the use of disposable trocars
is clearly diminishing. There are very high quality reusable
trocars in the market that avoid the use of disposable ones
(Figs 6A and B).
In general, trocars with various diameters are used in
surgical endoscopy. The standard sizes are 3.5, 5.5, 11, 12,
15 and 22 mm but there has been a recent trend towards
the use of smaller trocars, even for advanced procedures.
All trocars have a flapper or trumpet valve. Spherical and
flap valves allow a quickly change of operating instruments,
as this change can be carried out without activating the valve
mechanism. Trumpet valves are mostly found in telescope
trocars. The telescope is protected from contamination by
tissue and blood particles during insertion by pressing the
trumpet valve.
Trocars tips may be sharp or blunt, radially expanding,
shielded and/or transparent. Sharp, pyramidal trocar tips
can be positioned relatively easily; however, the sharp
edges can sometimes damage smaller blood vessels and
other organs. By using spherical, blunt, trocar tips, the
blood vessels are pushed aside and protected to a large
degree. Sometimes, however, greater pressure has to be
exerted during insertion. Since the skin incision for the
auxiliary puncture is carried out under transillumination
and the puncture itself is in full view, the choice of trocar
tip here can be regarded as being of secondary importance.
Better protection to prevent the trocar slipping out of the
intraperitoneal space is provided by sheaths with screw
threading. However, these cause increased trauma to
both the abdominal wall and the peritoneum. Trocar
reducers may facilitate the surgery in case you use smaller
instruments.
Equipment in Laparoscopic Surgery 7
Instruments
Dissection and grasping instruments: Dissect means
“methodically cut up (a body or plant) in order to study
its internal parts”. Dissection is probably the finest part of
a surgery. Almost all standard instruments available for
laparotomy are available in a specialized form to fit through
an endoscopic 3–20 mm port.
Grasping forceps have been designed for tissue
manipulation, and may be locking (ratcheted) and no
locking (nonratcheted). Some forceps are broad and flat,
while others are finer and made for delicate tissue handling
(Figs 7A and B).
Atraumatic stabilization of structures is achieved by
fine grasping forceps multiserrated and with a round tip.
With an atraumatic forceps the surgeon is able to expose
and perform the countertraction needed to dissect and to
suture. For example, prehension of the Fallopian tube or the
ureter. A Babcock-type atraumatic grasper with a ratcheted
scissors handle can be particularly useful in handling the
mesentery or adnexal structures.
Toothed forceps (claw forceps) are used to grasp and
liberate solid organs. In a laparoscopic cyst extirpation,
to fix the ovary properly and remove the cystic capsule, it
is crucial strong grasping forceps. Forceps with pointed
ends are used for tissue dissection and surgical plane
development.
Dissecting and grasping instruments are available
in either reusable or disposable forms. The disposable
instruments are typically less cost-effective, although they
have the advantage of being available (when properly
stocked), and the cutting edges are always sharp, whereas
no disposable instruments may be in the process of cleaning
8 Manual of Minimally Invasive Gynecological Surgery
A B
Figs 7A and B: Grasping forceps (atraumatic/fenestrated/dissectors/traumatic)
Fig. 8: Hook scissors
and resterilization, particularly where many laparoscopic
surgeries are performed. Most of the dissectors and
graspers have the availability of electrosurgery connection.
Biopsy forceps: They are used during diagnostic laparoscopy
to sample suspected endometriosis implants, or in ovarian
suspicious malignancy (before chemotherapy or during
second-look laparoscopy).
Scissors: These instruments may be straight, curved
or hooked. Delicate dissection can be carried out with
straight scissors. Curved scissors, in general, have the
same features as for straight scissors. In some cases, they
are easier to dissect with, because the curvature changes
the viewing angle. Hook scissors are particularly suitable
for transecting ligature fibers and for tissue transection
(Fig. 8). Scissors can be used to adhesiolysis, section of
coagulated tissue and sutures cutting. Some have an
electrical adapter so they can be combined with unipolar
or bipolar electrocoagulation.
Coagulation instruments: Most devices used for
coagulation during operative laparoscopy are adapted
from open surgery. More details about electrosurgery
were described in the chapter “Principals and use of
electrosurgery in laparoscopy”.
Concerning monopolar instruments there are different
tips available (Fig. 9A). There is a monopolar high-
frequency needle that can be retracted into the sheath
(Fig. 9B). Also a vast armamentarium of bipolar forceps
with various tips is seen with a coagulating probe (Fig. 10).
Needle holders: The figure below shows 5 mm needle
holders. These instruments are essential to perform suture
and knots. There are different types of needle holders. They
may have a straight or curved handle, as well as straight and
curved tips. The co-axial types with a locking system are
preferred to the pistol type needle holders (Figs 11A and
B). There are also automatic needle holders that after being
charged, put the needle in a 90º angle. In extracorporeal
sutures, the aim is to apply tension under a controlled way
(myomectomies, promontofixation, vaginal cuff closure),
a knot pusher is needful.
Suture passer devices: There are various types of sutures
passers available for closure of ports and transfacial ligature
(Fig. 12). The thread passer has a side slit to carry the thread
into the peritoneal cavity on one side to the trocar. Once
the thread is in the peritoneal cavity, the instrument is
introduced on the other fascia side and the thread is pulled
out closing the fascia defect caused, for example, by the
trocar insertion. This procedure should be performed under
laparoscopic view and guidance.
Intestinal probe: The intestinal probe is used to push
back the bowel in order to achieve a good view. It may be
important for endometriosis surgery to expose the rectum
or in sacrocolpopexy to deviate laterally the rectum and
sigmoid during the procedure.
 Equipment in Laparoscopic Surgery 9

A B
Figs 9A and B: (A) Monopolar instruments; (B) The monopolar high-frequency needle (Karl Storz): The tip of the needle can be
retracted into the sheath

Fig. 10: RoBi: new generation of rotating bipolar forceps and scissors

A B
Figs 11A and B: Needle holders by Karl Storz
10 Manual of Minimally Invasive Gynecological Surgery
Vaginal probe: It is very useful for exposing the vagina
mainly during deep endometriosis and prolapse surgeries
(Fig. 13).
Myomas holder: During a laparoscopic myomectomy,
it is difficult to stabilize a smooth, hard fibroid. Myoma
screws (5 mm and 10 mm) allow the surgeon to maneuver
Fig. 12: BERCI® fascial closure instrument by Karl Storz
Fig. 13: Vaginal probe
A B
Figs 14A and B: Myoma screw
the myoma and apply traction with improved exposition
and access. In case of a big myoma, it is better to use the
10 mm myoma screw (Figs 14A and B). Another alternative
for myoma fixation is the use of a strong tenaculum offering
you more mobility in the myoma traction points.
Tissue removal: In the past, laparoscopic surgeons
were faced with the difficult problem of tissue extraction,
and were often obliged to perform a suprapubic mini-
laparotomy or a transvaginal extraction.
There are several good alternatives available for
the surgeon to remove large volumes of tissue without
increasing the size of the laparoscopic access incisions.
Morcellators grasp, core and cut the tissue to be removed
into small pieces. These fragments are forced into the hollow
part of the instrument. Manual and automatic morcellators
are available. Steiner developed the electromechanical
morcellator, consisting of a motor-driven cutting tube. The
speed can be selected in three stages. It is possible, with
the aid of this morcellator, to extract even large amounts
of tissue from the abdomen, using the size 11 trocar, in a
short period of time. With 12 mm and 15 mm trocars, large
quantities of tissue can be extracted in this way within a few
minutes.
Automatic morcellators are more expensive but are
very effective and save time when large amounts of tissue
need to be removed (Figs 15A and B). It is obligatory
to observe the tissue that will be removed from the
moment it is divided from other tissues to its delivery
through the abdominal wall regardless of whether or not
it is removed in a tissue bag to prevent injury to adjacent
tissues. Because of the good cutting quality of the rotating
morcellator, the tissue structure is minimally damaged.
It also enables a reliable histological examination to be
carried out.

A B
Figs 15A and B: Rotocut® myoma morcelator
A B
Figs 16A to C: (A and B) Suction-irrigation devices; (C) The GORDTS/CAMPO—coagulating suction and irrigation cannula by Karl Storz
Tissue bags can be used to isolate tissue (e.g. tumor,
infected appendix) prior to removal with or without
morcellation. The tissue bag can be removed through a
secondary port site or through the infraumbilical port
once the camera has been removed. For some (e.g.
appendectomy), but not all types of laparoscopic surgeries,
the use of a tissue bag may decrease the risk of surgical site
infection or oncological dissemination. The tissue bag can
also be removed through the cul-de-sac after a culdotomy
(in alternative to a trocar port size enlargement).
Irrigation-suction: During diagnostic and surgical
laparoscopy, it is commonly necessary to drain fluids and
irrigate wound surfaces until they are clean and can be
viewed adequately. Irrigation is used to clear debris or
blood when bleeding is encountered, if a strong irrigation
pressure is applied it can be helpful to clearly identify
the origin of a bleeding. Some surgical teams defend that
irrigation can also be used for hydrodissection and creation
Equipment in Laparoscopic Surgery 11
C
of tissue planes. On other hand, many surgeons say that
irrigation should be avoided because it may interfere
with the CO2 pneumodissection of the retroperitoneal
spaces. It is important that these solutions are used at body
temperature.
Suction is performed either by means of a central
vacuum supply system or with an additional suction pump
that works usually better. Different laparoscopic suction
instruments have been designed to remove irrigation fluid
or intraperitoneal air and smoke. Combination suction/
irrigation devices are also available (Figs 16A and B).
A larger 10 mm suction-irrigation instrument is ideal for
removing blood clots when brisk bleeding is encountered
(pe. hemoperitoneum after an ectopic pregnancy
rupture).
In the market, there is available a suction-irrigation
device with a bipolar current tip that may be useful in
case of ovarian endometriomas and deep endometriosis.
 12 Manual of Minimally Invasive Gynecological Surgery
A B
Figs 17A to C: Uterine manipulators (Mangheskiar , Clermont-Ferrand® and Donnez®)
It is a more versatile device allowing blunt dissection,
coagulation, irrigation and fluids suction, simultaneously
(Fig. 16C).
Uterine manipulators: Safe, effective endoscopy,
requires adequate mobilization and stabilization of the
uterus and associated organs. Various combinations of
uterine sounds, cannulas, and dilators are available (Figs
17A to C). They are very useful for the uterus exposition
during procedures like hysterectomy, myomectomy,
adnexal surgery and endometriosis. Some surgeons even
say that “...if an uterine manipulator is properly used, it
makes half of the hysterectomy...”
Key Points
•• Almost all instruments available for laparotomy are now available
in a specialized form for laparoscopy.
•• The good knowledge of surgical instruments and equipment is
an important condition for the biggest success of a surgery and
avoidance of complications.
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